Basic Information
Provider Information | |||||||||
NPI: | 1750335667 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LI | ||||||||
FirstName: | RONGSHAN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 535 E CRESCENT AVE | ||||||||
Address2: |   | ||||||||
City: | RAMSEY | ||||||||
State: | NJ | ||||||||
PostalCode: | 074462922 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2016617280 | ||||||||
FaxNumber: | 2016617297 | ||||||||
Practice Location | |||||||||
Address1: | 100 KESTREL DR | ||||||||
Address2: |   | ||||||||
City: | COLLEGEVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 194262060 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6108315354 | ||||||||
FaxNumber: | 6108315358 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2006 | ||||||||
LastUpdateDate: | 09/22/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 47440 | WI | N |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 25MA08650800 | NJ | Y |   | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
ID | Type | State | Issuer | Description | 000030377S | 01 |   | HUMANA | OTHER | 34584000 | 05 | WI |   | MEDICAID |